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Gastroenterology. Swedish Family Practice Residency Didactics July 31, 2001. A quick trip through the GI track with brief stops at the esophagus, stomach, liver, colon, rectum and anus. And a little diarrhea. The Upper GI Tract. Esophagus Stomach Pancreas Gallbladder Liver.

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Swedish Family Practice Residency Didactics

July 31, 2001

A quick trip through the GI track with brief stops at the esophagus, stomach, liver, colon, rectum and anus.And a little diarrhea.
the upper gi tract
The Upper GI Tract
  • Esophagus
  • Stomach
  • Pancreas
  • Gallbladder
  • Liver
esophageal disorders
Esophageal Disorders
  • Disorders of motility
  • GERD
  • Inflammatory and

infectious disorders

  • Tumors
symptoms from the esophagus
Symptoms from the Esophagus
  • Dysphagia
  • Odynophagia
  • Chest pain
  • Regurgitation
disorders of motility
Disorders of Motility
  • Achalasia – Cancer, Parkinson’s, Chagas Disease (trypanosomiasis)
  • Spasm – Diffuse, Localized
  • Scleroderma
diagnostic studies
Diagnostic Studies
  • Barium swallow
  • Manometry
  • Long-acting nitrates
  • Calcium channel blockers
  • Dilation of LES (Achalsia)
  • Surgery (Spasm, Scleroderma)
  • Manage reflux (Scleroderma)
  • Prokinetic drugs (Scleroderma)
  • Frequent – 10% of US population
  • Occasional – 30% of US population
symptoms of gerd
Symptoms of GERD
  • Heartburn
  • Water Brash
  • Regurgitation
  • Dysphagia/odynophagia
  • Chest pain, hoarseness, chronic cough, wheezing
diagnosis of gerd
Diagnosis of GERD
  • Therapeutic trial
  • Endoscopy (if complicated)
  • Manometry (for placement of pH probe or prior to reflux surgery)
  • pH acid perfusion test (for diagnosis of unresponsive GERD)
treatment of gerd
Treatment of GERD

Mild Symptoms

  • Dietary modification
  • Lifestyle modification
  • Trial of patient directed

therapy with OTC antacids

or H2 antagonists

treatment of gerd13
Treatment of GERD

Non-responders, non-erosive disease

  • H2 antagonists
  • PPI’s
  • Promotility agents
  • 8-12 weeks of therapy
warning symptoms suggesting complicated gerd
Warning Symptoms Suggesting Complicated GERD
  • Dysphagia
  • Bleeding
  • Weight loss
  • Choking (acid causing coughing, shortness of breath , or hoarsness)
  • Chest pain
  • Longstanding symptoms requiring continuous treatment
treatment of gerd15
Treatment of GERD

Complicated GERD

  • GI workup with endoscopy
  • PPI’s
  • High-dose H2 antagonists
  • Antireflux surgery – no data on new procedures
inflammatory disorders of the esophagus
Inflammatory Disorders of the Esophagus
  • Pill-induced esophagitis – NSAID’s, steroids, doxycycline
  • Infective esophagitis – HIV, HSV, cytomegalovirus, candida
  • Corrosive – alkalis or acids
diagnosis and treatment
Diagnosis and Treatment


Treatment based on

results of endoscopy

esophageal tumors
Esophageal Tumors
  • 90% are malignant
  • Most are squamous cell
  • Most are associated with heavy alcohol and tobacco use
  • 8% of Barrett’s develop into adenocarcinomas
  • 5% 5-year survival but improving
diseases of the stomach
Diseases of the Stomach
  • Acid peptic disorders of the stomach and duodenum
  • Infections
  • Motor disorders
  • Cancer
acid peptic disorders
Acid Peptic Disorders
  • 5 – 10% of the US population will have PUD in their lifetime, 50% will recur
  • .0001% mortality rate
cause of pud
Cause of PUD

Imbalance between protective and aggressive factors

protective factors
Protective factors
  • Mucus and bicarbonate secretion of epithelial cells
  • Surface membrane of mucosal cells
  • PG E-1 and PG E-2
aggressive factors
Gastic acid




Alcohol (?)

Stress (?)

Diet (probably not)


Aggressive Factors
h pylori and pud
H. pylori and PUD
  • Almost all patients with H. pylori have antral gastritis
  • Eradication of H. pylori eliminates gastritis
  • Nearly all patients with DU have H. pylori gastritis
  • 80% of patients with GU have H. pylori gastritis
h pylori diagnosis
H. Pylori Diagnosis
  • Serology ($20-$200) – 90% sensitive, 95% specific – not good for following treatment
  • Biopsy ($250) – 98% sensitive – 98% specific
  • Urea breath test ($80-$100) – 95% specific, 98% specific – can be used to document eradication
  • Stool antigen test ($100-$150) – 90% sensitive, 95% specific – can be used to confirm eradication
natural history
Natural History
  • 20 – 50% heal untreated
  • 80% heal in 4 weeks of treatment
  • 75% recur in 6 – 12 months
  • More recur in patients with

H. pylori, smokers, NSAID users

  • Milk and tobacco slow healing
treatment of pud
Treatment of PUD
  • H2 blockers - $25 a month for generics
  • Maintenance dose same as treatment dose
  • 20% recur on maintenance vs. 70% on no treatment
  • PPI’s - $125 a month (Prilosec soon out in generic)
treatment of h pylori
Treatment of H. pylori
  • No therapy is 100%
  • Treatment markedly decreases recurrences of DU
  • Use of H2 blockers and PPI’s increases eradication rate and hastens relief of symptoms
  • PPI’s have intrinsic in vivo activity against H. pylori
diseases of the lower gi tract
Diseases of the Lower GI Tract
  • Constipation – 2% of US population report chronic constipation
  • Irritable bowel syndrome – a diagnosis of exclusion (CBC, colonoscopy, stool O&P, lactose difficiency, endoscopy)
diseases of the lower gi tract cont
Diseases of the Lower GI Tract, cont.
  • Malabsorption – long differential (consider if weight loss, muscle wasting, hair loss, malnutrition)
  • Inflammatory bowel disease – UC and Crohn’s disease
  • Mesenteric vascular disease
diseases of the lower gi tract cont31
Diseases of the Lower GI Tract, cont.
  • Diverticulosis (90% have

no symptoms)

  • Diverticulitis (infectious)
  • Infectious diarrhea
diagnosis of infectious diarrhea history
Diagnosis of Infectious Diarrhea - History
  • Work
  • Travel
  • Eating
  • Ill contacts
  • Recent antibiotics
  • HIV or immunocompromised
treatment of mild symptoms
Treatment of Mild Symptoms
  • Maintain hydration: sports drinks, diluted fruit juices, watery soups, pedialyte, WHO formula, IV fluids
  • Solids as tolerated but avoid milk and milk products
diagnosis of infectious diarrhea
Diagnosis of Infectious Diarrhea
  • Stool C&S, O&P (x1), fecal blood and leukocytes if no improvement in 48 hours or severe disease with bloody stools, fever, dehydration
  • Consider sigmoidoscopy

Pathogens requiring treatment – shigella, giardiasis, E. coli, pseudomembranous entercolitis, V. cholera


Pathogens that may require treatment – campylobacter, salmonella, amebiasis (5% carriage rate in the US, many are not pathogenic)

  • Most viral and bacterial causes of diarrhea resolve without treatment
  • Antibiotics may prolong or worsen diarrhea
diseases of the lower gi tract cont38
Diseases of the Lower GI Tract, cont.
  • Cancer – small bowel (rare), colon (6% incidence)
  • Anorectal diseases – cancer, hemorrhoids, pruritis ani, fissures
  • And hepatitis